Pain services and palliative medicine – an integrated approach to pain management in the cancer patient

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British Journal of Pain
2014, Vol. 8(4) 163 –171
© The British Pain Society 2014
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DOI: 10.1177/2049463714548768
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It is far more important to know the person who has the 
disease, than what the disease the person has.
Hippocrates
Introduction
It is estimated that up to 80–90% of patients with 
advanced cancer experience pain.1,2 Fortunately, the 
majority of these patients will have their pain managed 
satisfactorily by using simple guidelines as articulated 
in the World Health Organization (WHO) analgesic 
ladder. Approximately 90% of patients with cancer 
pain will have their symptoms controlled using this 
approach.3,4 In studies of self-reported poor pain con-
trol, this may fall to 70%.5 Based on the number of 
cancer deaths in the United Kingdom in 2011, up to 
48,000 patients suffer uncontrolled cancer pain per 
year.6 If the number of cancer survivors with chronic 
pain is taken into consideration, this number climbs 
further still.
Pain services and palliative 
medicine – an integrated approach 
to pain management in the cancer patient
Tony O’Brien1,2,3 and Christopher M Kane4
Abstract
The vast majority of cancer patients will experience pain during the course of their illness. Thankfully, in 
most instances, the consistent application of analgesic guidelines, tailored to the unique needs of each 
individual patient, will deliver a satisfactory outcome. These guidelines recommend the skilled use of 
analgesic medications, often in conjunction with a range of adjuvant therapies as may be required. Despite 
the consistent and rational application of such strategies, it is recognised that a small but significant 
proportion of cancer patients continue to experience more refractory pain. In addition, these patients may 
experience a plethora of unwanted dose-limiting side effects associated with their analgesic medication, 
sometimes even at low dose. All such patients with more complex and refractory pain syndromes require 
a more comprehensive review and many will require interventional therapy and/or adjuvant approaches. 
Unfortunately, the availability and accessibility of such services are variable. Even in circumstances in 
which palliative medicine and pain services co-exist in the same region, there may be poor integration 
between the two services. Each specialty area holds a unique set of skills and competencies, yet there 
is considerable overlap. Patient care and outcomes will be enhanced by establishing more formal 
relationships between these two specialty areas.
Keywords
Pain management, chronic pain, neuralgia, nociceptive pain, pain, intractable
1Marymount University Hospital & Hospice, Cork, Ireland
2Cork University Hospital, University College Cork, Cork, Ireland
3College of Medicine & Health, University College Cork, Cork, 
Ireland
4Academic Unit of Palliative Care, Leeds Institute of Health 
Sciences, School of Medicine, University of Leeds, Leeds, UK
Corresponding author:
Tony O’Brien, Marymount University Hospital & Hospice, Cork, 
Ireland. 
Email: tony.obrien1@hse.ie
548768 BJP0010.1177/2049463714548768British Journal of PainO’Brien and Kane
research-article2014
Original Article
164 British Journal of Pain 8(4)
Philosophy of palliative care
The importance of achieving and maintaining an opti-
mal level of pain and symptom control throughout the 
course of any progressive illness is highlighted in the 
WHO definition of palliative care.7 This quite proper 
focus on pain and symptom management may cause 
confusion in the minds of some observers. Good pain 
control is not the sole or even primary objective of pal-
liative care per se; it is merely a means to an end. Good 
pain control is not the end-point in itself; it is the start-
ing point. Improving individual quality of life is at the 
heart of palliative care philosophy and practice. 
Individual quality of life is a complex phenomenon 
that is not always easy to measure. However, we do 
know that it is always individual, multi-dimensional 
and dynamic.
Good pain and symptom management are one of the 
means by which patients are enabled and encouraged to 
live the life they choose to live, in the manner and setting 
of their choice, for the natural duration of their life. 
Good pain control, combined with skilled psychosocial 
and spiritual support, provides the foundation on which 
individual patients may build their life in the manner of 
their choice. Patients define their own quality determi-
nants, and it is the function of palliative care and indeed 
of healthcare, in general, to support and enable them in 
this regard to the greatest possible extent.
Palliative medicine physicians have significant exper-
tise in the management of pain in advanced cancer 
patient tailoring and adapting their approach to fit in 
with the patient’s biomedical and psychosocial frame-
work. There is potential for growth, development and 
enhanced synergies between palliative medicine and 
specialist pain services. Whilst the majority of patients 
will respond well to standard palliative medicine 
approaches to analgesia, a significant minority will ben-
efit from the unique skills and expertise of a specialist 
pain service. Close integration between the two special-
ist services will result in appropriate interventions being 
undertaken in a timely fashion, to the benefit of patients 
and their families. The primary focus of this paper is to 
explore the interface between palliative medicine and 
specialist pain services. It is not intended to provide a 
detailed review of advanced cancer pain management.It 
is not intended as a review of advanced cancer pain 
management, but seeks to highlight this area.
Evolving profile of palliative care
Over the past decade or more, the focus of palliative 
care has changed to include involvement at a much 
earlier stage of disease. In many instances, patients 
are referred from the moment of first diagnosis. Thus, 
palliative care services are involved with patient care 
throughout all stages of the cancer journey, including 
multi-modality neo-adjuvant treatments and all man-
ner of disease-modifying interventions. So, while pal-
liative care continues to incorporate end-of-life care, 
palliative care is not defined by end-of-life care.
Another change that has occurred in recent years is 
the integration of specialist palliative care services 
across a range of care domains, including acute hospi-
tals, community settings and free-standing hospice 
units. In essence, the service follows the patient’s jour-
ney at each and every stage.
Nature of pain
Pain in a cancer patient is a subjective, multi-dimen-
sional human experience, with complex interactions 
between sensory and emotional components.8 In the 
clinical context, one never sees pain. The clinician 
observes an individual patient’s emotional responses to 
his or her pain, which typically manifests as distress 
and suffering. The extent of the manifest distress is in 
part related to the severity of the pain. However, a vari-
ety of other factors, not least being the specific signifi-
cance that the patient attaches to his or her pain at that 
time, will also influence the extent of an individual’s 
distress. Thus, we observe intricate interactions 
between physiological, psychological, sociocultural, 
sensory, cognitive and behavioural dimensions.9 It is 
never possible to treat pain in an abstract sense; one 
may only treat the person with the pain. Thus, patients 
require a multi-faceted approach to pain and symptom 
management utilising pharmacological and non-phar-
macological strategies in conjunction with appropriate 
psychosocial therapies.10
Of course, we must understand the pathophysiol-
ogy of each individual pain, recognising that cancer 
patients willtypically have multiple pains.11 But a 
detailed pain assessment demands that we undertake 
a more holistic review of each individual patient 
in the context of his or her unique circumstances. 
Pain management requires a multi-dimensional and 
inter-disciplinary approach to assessment, and there-
after, therapeutic strategies will require the use of 
both pharmacological and non-pharmacological 
interventions.
Meeting the patient, not the pain
Wolpaw and Shapiro12 highlight the importance of 
establishing a connection with each individual patient 
that allows us to care for them as whole persons.
They identify four key components in this regard:
1. Seeing the patient as a unique individual;
2. Identifying shared experiences;
3. Demonstrating that we are observant and atten-
tive to the patient’s narrative and circumstances;
O’Brien and Kane 165
4. Indicating that we are open to a meaningful 
exchange/conversation.
In order to have a meaningful therapeutic relation-
ship with a patient, we must allow patients the opportu-
nity to say ‘this is who I am’. The absolute need to 
combine a high level of technical competence with a 
more human and compassionate approach to patient 
care is eloquently and poignantly portrayed in Professor 
Kieran Sweeney’s personal account of his cancer jour-
ney that was published in 2009.13 Professor Sweeney 
was a medical academic who developed a mesotheli-
oma. In this article, he describes with remarkable 
honesty his own individual experiences of living and 
dying with cancer. He commends the high level of tech-
nical competence that he so frequently encountered. 
Nevertheless, he also describes a profound sense of iso-
lation because of perceived failings in the relational 
aspects of care.
Clearly, we need to develop an open, honest and 
trusting relationship of equals between physician and 
patient. This relationship, like all other relationships, 
must be characterised by mutual respect and under-
standing. We must always remember that, irrespective of 
how technologically advanced medicine may become, 
the practice of medicine is always a social act.14 There is 
always a real person, with real fears and concerns, at the 
end of our needles and catheters and within the cham-
bers of our increasingly advanced imaging devices.
Standard approach to cancer pain 
management
Dating back to the early work of Dame Cicely Saunders 
and colleagues in the 1960s and 1970s, the unique 
safety profile and efficacy of the regular administration 
of oral opioids in the management of cancer pain were 
clearly demonstrated. These core principles of cancer 
pain management were subsequently endorsed and 
promoted by the WHO in the now-famous ‘analgesic 
ladder’. The regular administration of oral opioids, 
with careful attention to patient selection, drug selec-
tion and a proactive approach to ensure an optimal 
balance between analgesic effects and adverse effects, 
remains and will remain the basis of our approach to 
cancer pain management.
Extensive experience worldwide has confirmed the 
effectiveness of this approach in the vast majority of 
cancer patients. But therein lies a problem. If, as the 
available evidence confirms, we can achieve good or 
satisfactory analgesia by the application of relatively 
simple oral analgesic protocols in the vast majority of 
cases, one might be forgiven for starting to believe that 
the problem of cancer pain is largely a historical one. 
Nothing could be further from the truth.
Refractory pain
The published literature indicates that an acceptable 
level of analgesia is achievable using well-publicised 
protocols in 85–90% of cancer patients. This is 
undoubtedly good news for the majority of cancer 
patients. However, we must be mindful of the needs of 
those patients whose pain is refractory to standard 
approaches. Hoskin15 reports that 10–30% of people 
with advanced cancer still have inadequate pain con-
trol, despite optimised use of systematic analgesics. 
The timely application of interventional therapies nec-
essary to achieve and maintain good pain control is 
essential. Although interventional pain therapies are 
often effective in otherwise intractable pain, these ther-
apies are often under-utilised or withheld until the very 
end of life.16 The individual human and societal cost of 
uncontrolled pain in this significant cohort of patients 
is incalculable. Furthermore, if one practises medicine 
in the specialties of pain medicine or palliative medi-
cine, one may expect to see a much higher proportion 
of patients with more complex pain needs. Such 
patients are referred to these services precisely because 
their pain is not responsive to simple management 
strategies.
Refractory pain may be defined as pain that responds 
poorly to standard, conventional treatments. In addi-
tion to uncontrolled pain, these patients may be fur-
ther burdened by many unwanted adverse effects 
associated with the use of their medications.17 Thus, 
the most unsatisfactory circumstance whereby a 
patient continues to experience uncontrolled pain and 
is additionally burdened by the undesirable adverse 
effects of opioid medications is one of the most chal-
lenging issues in both palliative medicine and pain 
medicine.
Interface between pain medicine and 
specialist palliative care
Many patients with more complex and refractory pain 
syndromes will benefit from timely assessment by a 
comprehensive, inter-disciplinary pain service. In terms 
of the interface between palliative medicine and pain 
medicine, the situation is evolving rapidly. In the past, 
many hospice and specialist palliative care services had 
limited access to or availed little of the particular exper-
tise of colleagues in pain medicine. Historically, hospice 
services were particularly associated with the ‘care of 
the dying’, and the pervading culture was largely one of 
non-intervention. The culture has now changed such 
that the modern specialist palliative care service works 
in a more integrated fashion, embracing as appropriate 
all the technological developments in medicine. 
Nowhere is this more evident than in the application of 
166 British Journal of Pain 8(4)
interventional radiology techniques for the relief of 
burdensome symptoms. Such techniques include 
draining malignant pleural effusions or ascites, decom-
pressing an obstructed renal or biliary tract, position-
ing a stent in an obstructed oesophagus or colon, 
enteral feeding devices, using a vascular stent in the 
superior vena cava (SVC) or inferior vena cava (IVC), 
tumour embolisation, vertebroplasty and so on.
But to what extent are pain specialist and palliative 
care specialists availing of each other’s expertise? 
Several high-level reports have recommended closer 
ties between palliative care services, cancer services 
and pain services to improve patient experience and 
outcomes.18–20 There is a scarcity of literature on the 
subject of the interface between pain services and pal-
liative medicine services for cancer pain, with only two 
national surveys having been published since 2002.21,22 
As both these surveys are now fairly outdated, it is dif-
ficult to ascertain whether effective provision of ser-
vices for cancer pain exists.
Linklater et al. in 2002 reported on a postal survey 
of palliative medicine physicians that revealed marked 
under-utilisation of specialist pain management teams 
by hospice services. While most palliative medicine 
respondents indicated that they had access to such ser-
vices, over half had used the services of a pain specialist 
less than four times in the previous 12 months. Previous 
surveys of palliative medicine consultants have found 
that only 40% of respondents felt that regular contact 
with a pain specialist would be of benefit and only 65% 
felt that‘ad hoc’ contact would be useful. While they 
thought that up to 8% of patients may benefit from an 
interventional procedure, only 20% of palliative care 
doctors believed that more input from pain specialists 
was required.21
A variety of reasons for this apparent under-utilisa-
tion are proposed, including a lack of formal struc-
tures, geographical isolation of hospice units, different 
management and governance structures between the 
services and a lack of experience among palliative med-
icine physicians.
In 2007, Kay et al.22 reported on a similar postal 
survey of pain specialists across the United Kingdom. 
Again, referral rates from palliative medicine were low 
and joint consulting arrangements were ‘rare’. The 
authors concluded that
Although pain specialists have a vital role in the 
management of patients with advanced cancer, …. few 
anaesthetists are involved in the delivery of an integrated 
palliative care service and only a small proportion of 
patients who could benefit from advanced pain 
management techniques do so.
It is noteworthy that joint consultations were uncom-
mon, with about 50% of pain specialists never having 
done a joint consultation. Two-thirds were using time 
outside their job plan to accommodate the ad hoc refer-
rals of palliative patients to allow them to be seen more 
quickly. However, those who had formally allocated 
time had a significantly increased amount of referrals 
for the management of cancer pain.
More strikingly, 65% of respondents either stated 
there were no pain specialists available for the palliative 
medicine multi-disciplinary team (MDT) or they did 
not know if there was one.
There was also a significant variability between 
regions in the types of procedure performed. Contrary 
to the common belief among palliative medicine con-
sultants that the role of the pain specialist should be 
limited to interventional procedures, pain specialists 
felt they had a significant role to play. Of those ques-
tioned, 10% did work jointly with palliative medicine, 
and this group saw a significant increase in referrals. 
This fact highlights the need to increase joint working 
and the importance of formal arrangements in order to 
best meet the needs of patients.
These surveys are now becoming outdated, and it is 
difficult to be precise as to the current picture, but 
there remains a consensus of opinion that patients are 
often referred too late to specialist pain services to 
benefit optimally from the available expertise. 
Anecdotally, there are reports of successful structured 
and funded collaboration between specialist palliative 
care and pain services, but this is not widespread. The 
scope for collaboration on clinical, research and teach-
ing initiatives is enormous and remains seriously 
under-developed.
There is an apparent lack of understanding and aware-
ness among colleagues from both specialties regarding 
the role and competencies of colleagues from the other. 
There is clearly a need for more interaction and shared 
education experiences between palliative medicine 
physicians and pain specialists, and this should begin 
during training years and at the earliest opportunity.
However, the previously mentioned studies may not 
fully capture the complexity and nuances of the problem. 
In a more traditional model defining the interface 
between palliative care and pain management teams, the 
pain specialist was typically invited to review only those 
patients who had failed every possible opioid therapy 
delivered over protracted periods of time. Not infre-
quently, clinicians followed the ‘analgesic ladder’ in a 
methodical way and considered a possible Step 4 of 
interventional pain services only after all other modali-
ties of care had failed.
Worst-case scenario
Consider the following unsatisfactory scenario. A 
patient with complex pain needs that are proving 
O’Brien and Kane 167
refractory to multiple analgesic approaches is under 
the care of a palliative medicine service. In desperation, 
a colleague from pain medicine is now invited to review 
an increasingly distressed and frustrated patient, often 
accompanied by a very angry and despondent family, 
with escalating levels of distress and anxiety. In many 
instances, the pain specialist has no meaningful rela-
tionship with the palliative care service and is now 
meeting the patient and family for the first time. Unless 
the pain specialist has dedicated clinical sessions at the 
hospice, this review may be undertaken in the late 
evening when neither the patient nor the pain special-
ists are performing at their very best. To compound 
the issue, the referral to the pain service may be repre-
sented to the patient as a ‘guarantee’ of almost instant 
and sustained pain relief. Sometimes, the expectations 
created around interventional pain services are totally 
unrealistic. Surely, there must be a better way to 
organise matters.
Coming together – for better, for 
worse
At the outset, it is acknowledged that there is consider-
able overlap and complementarity between specialist 
palliative care and specialist pain management services. 
Each has a separate and distinct set of skills and compe-
tencies, and each shares a common ‘middle-ground’. 
Both disciplines must establish close, professional and 
respectful relationships and gain an appreciation of their 
complementary roles. This will only be achieved if col-
leagues from specialist pain services are fully integrated 
into the specialist palliative care team. In this regard, the 
pain specialists must have a minimum number of 
defined sessions each week at the specialist palliative 
care unit or service. In the event that the specialist pal-
liative care service and the pain service are funded sepa-
rately and have different governance structures, it will be 
necessary to have a formal service agreement. This will 
create the opportunity for relationship building and 
understanding; for shared patient review and discussion 
and for collaborative research, audit and educational 
activity. Inviting colleagues from pain services to review 
only those patients with the most intractable and pro-
tracted pain management problems is an entirely inap-
propriate use of a pain service. The ‘ad hoc’ strategy is 
defunct, and we need to move forward to a fully inte-
grated and accessible model of service provision.
As previously identified, palliative medicine special-
ists may view pain specialists as ‘technicians’ whose 
role is limited to performing ‘nerve blocks’ or estab-
lishing drug delivery systems for spinal analgesia. 
Again, this portrays a very limited and entirely inaccu-
rate picture of the role of the pain specialist. Pain spe-
cialists need to be involved in the overall assessment 
and management of patients with more complex pain 
problems. They may advise on a range of investigative 
and therapeutic strategies that include, but are not 
limited to, interventional procedures. Equally, we all 
must get better at identifying those patients with more 
complex and challenging pain syndromes at an earlier 
stage in the disease trajectory. All such patients should 
have direct access to a comprehensive pain assessment 
with input from a fully integrated multi-professional 
team. And, as the pain specialists will gain a greater 
understanding and appreciation of palliative care strat-
egies, so also will palliative care specialists gain a 
greater understanding of pain specialist approaches, 
including interventions. In addition to medical and 
nursing personnel, we must also remember the impor-
tant function of pharmacy colleagues in supporting 
optimal patient care.
The British Pain Society23 has developed chronic 
pain pathway maps for other forms of chronic non-
cancer pain. Their aim is to provide consensus-based 
pathways thatreflect the best available evidence. As in 
many areas of pain management, robust scientific evi-
dence to support specific strategies is all too frequently 
lacking. Thus, there is a self-evident need for more 
large-scale studies.
An inconsistent partnership
In terms of cancer pain management, the British Pain 
Society has produced, in association with the Royal 
College of General Practitioners and the Association 
for Palliative Medicine of Great Britain and Ireland, a 
‘perspective’ document on cancer pain management.24 
The document notes the need for improved pain man-
agement in palliative care and observes ‘an inconsistent 
partnership between the specialties of pain medicine and 
palliative medicine’. The document summarises the 
barriers to links between specialist pain management 
and palliative medicine, and these are reproduced in 
Table 1.
Addressing the subject of invasive procedures for 
cancer pain, the British Pain Society’s publication 
notes that
There is good evidence for the effectiveness of a coeliac 
plexus block and intrathecal drug delivery; …..and, where 
applied appropriately and carefully at the right time, these 
procedures can contribute enhanced pain relief, reduction 
of medication use and a markedly improved quality of life.
In addition, the British Pain Society cancer pain docu-
ment also cites relatively good results associated with 
the use of anterolateral cordotomy.
Clearly, we need more evidence-based protocols to 
inform and guide clinicians. However, notwithstanding 
the guidelines, each clinician must make his or her own 
decision with due regard to the individual patient’s 
168 British Journal of Pain 8(4)
unique set of circumstances. Even if the clinician is 
happy to proceed to intervention, access to the neces-
sary facilities may prove problematic as reported in a 
survey of Australian palliative medicine consultants who 
highlighted their difficulties in accessing services.25 
Access to theatre facilities with suitable imaging is 
indeed sometimes problematic and is not a uniquely 
Australian problem. Such access problems represent a 
block to timely interventions and treatment. It is not 
always ideal, or even possible, to transfer a frail palliative 
care patient from a hospice setting to a local or regional 
hospital for a pain intervention. Therefore, hospice units 
might usefully consider developing on-site facilities to 
support anaesthetic interventions. In addition to a suit-
ably equipped theatre, waiting room and recovery 
rooms, pharmacy, secretarial and storage facilities will 
also be required. Such a facility may not be fully utilised 
by palliative care patients. As such, the hospice unit 
might make the facility available to other non-specialist 
palliative care patients who require such interventional 
treatments. At a regional level, not every procedure or 
intervention can be safely provided at every site. It will 
be necessary to concentrate the more complex proce-
dures in a regional centre to ensure adequate expertise 
and competence.
Illustrative procedures/approaches
There are a plethora of interventional techniques avail-
able, but for the purposes of this article, we wish to focus 
on three interventions in particular – percutaneous coe-
liac plexus block, intrathecal drug delivery systems 
(ITDDs) and percutaneous cervical cordotomy (PCC). 
It is beyond the scope of this article to attempt to sum-
marise the range of interventions that might be used.
Coeliac plexus block
The coeliac plexus contains pain fibres from the pan-
creas, spleen, small bowel, diaphragm liver, adrenals, 
kidneys aorta, and ascending and proximal transverse 
colon. As such, a coeliac plexus block may have some 
benefit in treating pain originating from these areas. It 
is most commonly used to treat direct invasion of the 
coeliac plexus from pancreatic cancer.26
A systematic review in 2013 of coeliac plexus block 
for upper abdominal cancer pain, which included a 
meta-analysis of five studies containing 295 patients in 
total (149 vs 146), showed that pain was improved sig-
nificantly up to 1 month following treatment compared 
to those on pharmacotherapy alone. Even when pain 
scores were no longer significantly better a month after 
procedure, patients were on significantly less opiate 
compared to those who had not had the procedure. 
Although there was a transient increase in hypotension 
and diarrhoea following the procedure, the patient 
group also had less nausea, vomiting and constipation 
possibly related to reduced opioid consumption.26 A 
review by the Cochrane collaboration of coeliac plexus 
blocks in pancreatic cancer concluded that there is evi-
dence to show superiority of coeliac plexus block over 
standard therapy, although at present there are less 
adverse effects than those caused by opioids, which 
should be another important consideration.27
In terms of when the block should be performed, a 
randomised control trial in 2013 looked at patients with 
pancreatic cancer. One group had a coeliac plexus block 
performed after initial meeting and the other had medi-
cal management to reduce baseline pain, and then the 
block was performed. The latter group had better pain 
control, less opioid consumption and better quality of 
life scores compared with the early intervention group.28
It should be noted that these studies often do not 
compare the treatment with those on neuropathic 
agents, and this remains one area for further research. 
Palliative medicine professionals must be mindful of 
the need to reduce the baseline opioid dose following a 
successful coeliac plexus block to minimise the risk of 
emergent opioid toxicity. They must also be aware of 
the complications associated with coeliac plexus block, 
Table 1. Barriers to links between specialist pain management and palliative medicine.
Short survival of patients following referral to palliative care services
Funding of the service
Time on the part of the pain specialists for proper assessment and discussion
Facilities for performing interventions may not be easily accessible
Complexity/lack of real understanding
Staff training in the management of pumps and catheters
Pharmacy issues; procurement of solutions/availability of preservative-free opioids/lack of sterile facilities for making up 
infusions
Cost of implanted devices
Who is going to manage neuraxial infusions at home
Lack of availability of pain specialists out-of-hours
The palliative care doctor may be unaware of potential benefits/unsure how to access expertise
The pain doctor may not be adequately trained in the management of cancer pain/selection of an appropriate technique
O’Brien and Kane 169
including hypotension, diarrhoea, and the more seri-
ous neurological complications of paraplegia, leg 
weakness, sensory deficits and paresthesias. Four cases 
of paraplegia were reported in one series of 2730 
patients undergoing coeliac plexus block.29 This dev-
astating complication was attributed either to direct 
injury to the spinal cord or to spinal infarction second-
ary to spasm of the spinal artery. Although this was 
from a retrospective postal survey, the true prevalence 
is unclear.
This evidence highlights the importance of close 
working between pain and palliative medicine as a joint 
medical and interventional approach could be per-
formed at an earlier stage, resulting in better pain con-
trol and better quality of life. Either service working 
individually would be unlikely to provide the same 
level of outcome.
ITDDs
ITDDs are appropriate for use in patients with a vari-
ety of pain pathologies related to cancer, including 
neuropathic pain. Consensus guidelines for the use of 
ITDDs were published in 2011, which promoted a 
phased approach from the most conservative manage-
ment stepping up to ITDD systemsfor refractory can-
cer pain or where significant adverse effects existed.30 
Typically, patients whose cancer pain cannot be ade-
quately controlled on less invasive therapies without 
unacceptable side effects should be considered for an 
ITDD system. Spinal analgesia has been shown to 
offer good palliation in palliative care patients.31 A ran-
domised controlled trial in 2002 showed that in 
patients with complex pain on high doses of opiates 
(equivalent to 260 mg oral morphine per day), the use 
of ITDD significantly improved pain scores and alert-
ness while reducing drug toxicity and improving sur-
vival at 6  months compared to best medical 
management.32 Patient-activated dosing using ITDD 
systems as opposed to continuous infusion also showed 
significantly reduced pain scores and adverse effects.33 
In continuous intrathecal infusions, the opioid is often 
combined with a local anaesthetic agent.
Despite this evidence base, there remain significant 
problems with the implementation of this approach 
into clinical practice. An audit of use in the United 
Kingdom in 2008 showed significant variation, with 
ITDD services having emerged in an ad hoc way. Thus, 
there is a geographical lottery in terms of accessing this 
pain management approach.34 Implanted devices are 
the most convenient although they do require on-going 
support and management. They are compatible with 
the patient being at home if that is his or her choice.
While this is clearly an effective measure of pain 
control for some patients, it is also clear that it is only 
feasible in an environment that not only identifies suit-
able patients at an early enough stage to benefit from 
analgesia but also has on-going close connection 
between services to deal with them post-insertion. An 
integrated cancer pain service model in this situation 
would allow for training and education to be imple-
mented with accessible support for those looking after 
these patients in the community.
PCC
PCC, a neurodestructive technique, is indicated for 
any unilateral pain below C5. In this procedure, an 
attempt is made to ablate the spinothalamic tract on 
the side of the spinal cord opposite to the site of the 
pain. Cordotomy can be particularly useful for chest 
wall pain associated with mesothelioma. Its evidence 
base is small but what exists suggests that significant 
pain control can be achieved.35 It is discussed here as 
an example of both a problem and an example of inte-
grated working.
Currently in the United Kingdom, only a few sites 
offer percutaneous cordotomy.35 There is a consensus 
of opinion that a significant number of patients that 
may benefit from it are never referred for practical and 
logistic reasons. This demonstrates the need for not 
only a local or regional structure for integrated work-
ing, but it is also required at a national level to ensure 
that centres providing all procedures are distributed 
evenly across the country.
It is also an area where coordinated thinking is likely 
to increase both knowledge and understanding of the 
use, benefits and risks of this procedure. In 2011, a 
pilot study of the invasive neurodestructive procedures 
in cancer pain (INPiC) conducted a systematic review 
of cordotomy use for mesothelioma and concluded 
that good pain relief in most patients on all pain out-
come measures was achieved.36
Notably though, in order to provide governance for 
the clinicians performing these procedures and to gain 
a larger evidence base for on-going research, a national 
cordotomy registry was developed. This should negate 
some of the innate problems in gaining evidence to 
support implementation of cordotomy services in 
other areas.36
Conclusion
The above interventions highlight three different 
examples of circumstances in which interventional 
pain techniques may yield significant and meaningful 
benefit for patients. Indeed, many patients will 
undoubtedly continue to experience uncontrolled 
pain and/or suffer unacceptable side effects without 
such interventions. Thus, such approaches to service 
170 British Journal of Pain 8(4)
development are not an optional extra, they are an 
absolute necessity.
There is an urgent need to develop national policy 
in this regard that will provide the blueprint for loco-
regional development and integration of pain manage-
ment and specialist palliative care services. This will 
support enhanced educational, audit and research 
activity in addition to ensuring better patient out-
comes. Thus, we must develop clear local, regional and 
national structures to support a fully comprehensive 
and integrated pain management service within all 
specialist palliative care services. Equally, all pain man-
agement services must have easy access to specialist 
palliative care support as and when required. The era 
of ‘ad hoc’ arrangements is over.
There is always more to analgesia than analgesics. (Robert 
Twycross)
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding 
agency in the public, commercial or not-for-profit sectors.
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Don’t forget to save the date to attend
the British Pain Society’s 48th ASM in Glasgow
21 April – 23 April 2015
Why you should attend:
 • Network with colleagues
 • Raise questions, partake in debates and discuss outcomes
 • Meet with poster exhibitors and discuss their research
 • Meet with technical exhibitors and hear about their products and services
 • Discuss your own research
We look forward to seeing you in Glasgow.
Annual Scienti� c Meeting 
21 April – 23 April 2015
Glasgow
Save the date